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Experience. Integrity. Advocacy.

Eligibility, Hardship Exemptions, and Special Status: Decoding the Vocabulary of MIPS

As more and more details of the MIPS program are distributed, it would be easy for providers to get confused about the difference between phrases like “special status,” “eligibility requirements,” and “hardship exemptions.” In fact, it’s easy even for the Centers for Medicare and Medicaid Services (CMS) to get confused.

On July 24, CMS sent out a notice indicating providers with a designated “special status” would be exempt from the MIPS program. The problem is, that’s not true.

So what does “special status” mean? Who qualifies for a hardship exemption? And are you even eligible to participate in the program?

Eligibility Requirements

Let’s start with eligibility requirements. In order to participate in MIPS (which, actually means you must participate or be subject to negative payment adjustments), providers must meet all of the following guidelines:

  • You practice as one of the following provider types: physicians (including doctors of medicine, osteopathy, dental medicine, dental surgery, podiatric medicine, or optometry; osteopathic practitioners, and chiropractors); physicians assistants; nurse practitioners; clinical nurse specialists; or certified registered nurse anesthetists, OR you are part of a group that includes such clinicians.
  • You bill more than $30,000 in Medicare Part B allowable charges and have more than 100 Part B-enrolled Medicare beneficiaries (as a group, if you are participating in the MIPS group reporting option, or as an individual, if you are participating in the MIPS individual reporting option.
  • You are enrolled in the Medicare program for the first time prior to the current participation year.
  • You are not participating in an Advanced APM as either a Qualifying APM Participant (QP) or Partial QP

On the flipside, that means you are not eligible and do not have to participate in MIPS if any of the following apply:

  • You enrolled in Medicare for the first time in 2017.
  • You participate in an Advanced APM as either a Qualifying APM Participant (QP) or Partial QP.
  • You bill Medicare for $30,000 or less annually as an individual. (Your whole group is ineligible if the group bills Medicare for $30,000 or less.)
  • You provided care for 100 Medicare patients or fewer annually as an individual. (Your whole group is ineligible if the group provides care for 100 Medicare patients or fewer.)
  • You are not in a MIPS-eligible specialty.

For 2017, CMS will review providers’ eligibility at two different times. Providers who are exempt during the first review are not re-reviewed. CMS completed the first review for 2017 participation in December 2016 by examining Medicare Part B Claims data from September 1, 2015, through August 31, 2016, and PECOS data. CMS will complete a second review for 2017 participation in December 2017 by analyzing claims from September 1, 2016, through August 31, 2017, and PECOS data. Providers who joined a new practice in 2017 will have their eligibility evaluated during the second review period.

To see how CMS calculated the eligibility of a specific provider for 2017, enter their NPI in CMS’ MIPS Participation Status Lookup tool.

If you are eligible to participate in MIPS based on the above criteria, then you must participate or face a negative payment adjustment, which is 4 percent in 2017. However, keep in mind that CMS has allowed minimal participation in 2017 to avoid excessive penalties in this inaugural year via their “Pick Your Pace” program.

But what about hardship exemptions or special status? you might be thinking. How do they affect my eligibility?

Actually, neither affect eligibility. However, they do affect how you will participate in the program and how your score will be calculated. Let’s look at each one.

MIPS Hardship Exemptions

MIPS hardship exemptions are available for providers who meet certain criteria that prevents them from meaningfully using certified electronic health record technology (CEHRT) that is required for participation in the advancing care information performance category of MIPS.

Providers who meet the criteria would not be accountable for meeting the performance and reporting guidelines of the advancing care information performance category, and the 25 percent weighting of that category would be reallocated to the quality performance category. That means providers with a hardship exemption would have their 2017 MIPS score calculated primarily by the quality performance category (85 percent) and to a lesser degree by improvement activities (15 percent).

Hardship exemptions may be permitted to providers who submit their application indicating one of the following criteria:

  • Insufficient Internet Connectivity
  • Extreme and Uncontrollable Circumstances
  • Lack of Control over the availability of CEHRT

According to CMS, simply lacking CEHRT does not qualify a MIPS-eligible clinician or group for reweighting.

The deadline to submit hardship exemptions for the 2017 performance year currently is March 31, 2018. That deadline was implemented in the 2017 Quality Payment Program final rule; however, in the 2018 proposed rule, CMS hopes to change that deadline to December 31, 2017.

In the meantime, CMS is encouraging MIPS eligible clinicians to apply for exemptions early as they expect to process the applications on a rolling basis. According to an email from the Quality Payment Program Service Center, CMS will notify the public when a deadline is finalized to provide advance notice and ample time to make their submissions.

EHR Incentive Program Exemptions

Another exemption helps providers who are transitioning to MIPS to avoid a penalty under the EHR Incentive Program in 2018, the final year for that program. Eligible professionals who would be first-time participants in the CMS EHR Incentive Program in 2017 have until October 1, 2017, to attest and avoid payment adjustments in 2018.

According to CMS, this one-time hardship exception for the Medicare EHR Incentive Program 2018 payment adjustment is being offered “to provide EPs ample time to collaborate with their EHR vendors and adjust to the new reporting requirements in the advancing care information performance category of the MIPS.”

As such, an exemption from the final year of the CMS EHR Incentive Program does not exempt providers from their first year of MIPS, and in fact, it requires them to participate in the MIPS advancing care information performance category.

Here are the criteria for first-time participants who want to apply for this one-time exemption from the 2018 payment adjustment:

  • The EP is a first time participant in the EHR Incentive Program in 2017 and intends to participate in the Medicare EHR Incentive Program in 2017, and
  • The EP is transitioning to MIPS for the 2017 performance period, and
  • The EP intends to report on measures specified for the advancing care information performance category under the MIPS in 2017.

Special Status

Now let’s talk about special status.

CMS analyzes Medicare claims data to determine if MIPS-eligible providers operate under certain circumstances that qualify them for adjustments to the way they perform in and are evaluated under the MIPS program.

CMS has identified five different circumstances that move Individual clinicians and group practices into a special status, including:

  • Small practice: The practice that the clinician is billing under, or the practice itself for groups, has 15 or fewer clinicians.
  • Non-Patient-Facing: The clinician has 100 or fewer Medicare Part B patient-facing encounters (including Medicare telehealth services) during the Non-Patient-Facing determination period, or for groups, the practice has more than 75% of the NPIs under the practice’s TIN meeting the individual guideline. Download CMS’s list of non-patient-facing encounters here.
  • Health Professional Shortage Area (HPSA): The individual clinician, or at least one clinician in the practice for groups, practices in areas designated HPSA under section 332(a)(1)(A) of the Public Health Service Act.
  • Rural: The individual clinician, or at least one clinician in the practice for groups, practices in zip codes designated as rural, using the most recent Health Resources and Services Administration (HRSA) Area Health Resource File data.
  • Hospital based: The clinician, or the practice for groups, furnishes 75% or more of their covered professional services in the inpatient hospital, on-campus outpatient hospital, or emergency room settings (based on place of service codes) during the applicable determination period.

CMS will evaluate provider’s claims during two different review periods to determine the number of Non-Patient-Facing encounters. For 2017, those review periods will run concurrently with the review periods for the low volume threshold: December 2016 by examining Medicare Part B Claims from September 1, 2015, through August 31, 2016, and in December 2017 by analyzing claims data from September 1, 2016, through August 31, 2017.

So what does a “special status” designation mean for your MIPS participation? The chart below outlines the adaptations by status and reporting category.

Status Quality Improvement Activities Advancing Care Information
No Special Status Complete six measures, including one outcome measure. Groups of more than 15 clinicians may also submit the readmissions measure. Attest that you completed up to 4 improvement activities for a minimum of 90 days. Report measures using Option 1: Advancing Care Information Objectives and Measures or Option 2: 2017 Advancing Care Information Transition Objectives and Measures.
Small Practice Complete six measures, including one outcome measure. Attest that you completed up to 2 activities for a minimum of 90 days. Report measures using Option 1: Advancing Care Information Objectives and Measures or Option 2: 2017 Advancing Care Information Transition Objectives and Measures.
Non-Patient-Facing Complete six measures, including one outcome measure. Groups of more than 15 clinicians may also submit the readmissions measure. Attest that you completed up to 2 activities for a minimum of 90 days. Automatically exempt from ACI category. Weighted scoring % reallocated to Quality category
HPSA Complete six measures, including one outcome measure. Groups of more than 15 clinicians may also submit the readmissions measure. Attest that you completed up to 2 activities for a minimum of 90 days. Report measures using Option 1: Advancing Care Information Objectives and Measures or Option 2: 2017 Advancing Care Information Transition Objectives and Measures.
Rural Complete six measures, including one outcome measure. Groups of more than 15 clinicians may also submit the readmissions measure. Attest that you completed up to 2 activities for a minimum of 90 days. Report measures using Option 1: Advancing Care Information Objectives and Measures or Option 2: 2017 Advancing Care Information Transition Objectives and Measures.
Hospital-Based Complete six measures, including one outcome measure. Groups of more than 15 clinicians may also submit the readmissions measure. Attest that you completed up to 4 improvement activities for a minimum of 90 days. Automatically exempt from ACI category. Weighted scoring % reallocated to Quality category.

Remember, eligible professionals with or without a “special status” designation can apply for a hardship exemption to have the ACI weighted scoring percentage reallocated to the Quality reporting category. As indicated above, hospital-based and non-patient-facing individuals and groups are automatically exempted and do not need to apply.

For more information about your eligibility and any special status designations, review your participation letter from CMS, which was sent to clinician offices in late April and early May 2017. Download a sample letter here. Or, you can enter your NPI in CMS’ MIPS Participation Status Lookup tool to see your own personalized information.

Also, the American Medical Association has developed a tool called MIPS Action Plan to help you plan for participation in the 2017 MIPS program. It’s not too late to avoid a 4 percent negative payment adjustment and possibly earn a small positive payment adjustment by getting started today.

Finally, get more information about the MIPS program in general and plans for year 2 of MIPS (including new eligibility requirements and changes to exemption and special status guidelines) by reading earlier CIPROMS articles:

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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